Failure to Provide Adequate Supervision During Incontinent Care Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact but physically dependent on staff for activities of daily living (ADL) and at high risk for falls, was not provided adequate supervision during incontinent care. The resident had a history of impaired mobility, rheumatoid arthritis, and a previous femur fracture, and required extensive assistance with bed mobility. During the incident, a CNA was providing incontinent care with the resident's bed in a high position and turned away from the resident to retrieve an adult brief from the over bed table, leaving the resident unsupervised. While the CNA was turned away, the resident lost her grip on the side rail and fell from the bed, resulting in a fractured right femur. The resident was found on the floor by staff, complaining of significant pain, and was subsequently transferred to the emergency room where the fracture was confirmed. The incident report and staff interviews confirmed that the CNA did not ensure the resident was secure and safe in the bed before turning away, and the bed was left in a high position, increasing the risk of injury. Interviews with the resident and staff revealed that the resident was unable to hold onto the side rails for long due to arthritis, and the CNA was reportedly distracted, possibly using a cell phone during care. The failure to maintain supervision and ensure the resident's safety during care directly led to the resident's fall and injury. The deficiency was identified as immediate jeopardy due to the serious harm that resulted from the lack of supervision.